Detailed Step-by-Step Guide to Laparoscopic Splenectomy by Dr. Roshni Malhotra MBBS, MS, M.MAS

1. Preoperative Preparation:

   • Obtain informed consent.
   • Conduct a complete preoperative workup, including blood tests, imaging studies, and immunizations against encapsulated organisms if splenectomy is elective.
   • Ensure the patient fasts according to standard guidelines.

2. Anesthesia:

   • Administer general anesthesia.
   • Secure the airway with intubation.

3. Patient Positioning:

   • Position the patient in the right lateral decubitus position, with the left side elevated at about 30 to 45 degrees.
   • Secure the patient to the table using appropriate supports to prevent shifting during the procedure.

4. Team Positioning:

   • The surgeon stands at the patient’s abdomen, facing the patient’s back.
   • The first assistant stands opposite the surgeon, on the patient's left side.
   • The scrub nurse or technician is positioned at the lower end of the table, with the surgical instruments.

5. Monitor Placement:

   • Place the monitor at the level of the patient’s head, directly in the surgeon's line of sight.

6. Establishing Pneumoperitoneum:

   • Create a pneumoperitoneum by insufflating the abdomen with CO2 gas, typically through a Veress needle or a direct trocar insertion at the umbilicus.

7. Port Placement:

   • Insert the first 10-12 mm trocar at the umbilicus for the camera.
   • Place three additional ports: a 10-12 mm port in the left subcostal area along the midclavicular line, a 5-10 mm port in the left subcostal area along the anterior axillary line, and another 5-10 mm port in the left lower quadrant.

8. Exploration and Mobilization:

   • Insert the laparoscope and inspect the abdominal cavity.
   • Begin mobilizing the spleen by incising its ligamentous attachments, starting with the splenocolic ligament and moving to the splenorenal and splenophrenic ligaments.

9. Vascular Control:

   • Carefully dissect and ligate the splenic artery and vein. Use clips, staples, or vascular sealing devices as appropriate.

10. Spleen Dissection:

    • Continue the mobilization of the spleen, ensuring careful hemostasis.
    • Fully mobilize the spleen from all attachments, allowing it to be freely movable within the abdomen.

11. Spleen Removal:

    • Place the spleen in a retrieval bag.
    • Morcellate the spleen within the bag, if necessary, and remove it through an enlarged port site or a small additional incision.

12. Hemostasis and Inspection:

    • Inspect the operative field thoroughly for bleeding.
    • Achieve hemostasis as needed using cautery, clips, or other hemostatic agents.

13. Closure:

    • Desufflate the abdomen and remove the trocars.
    • Close the port sites, with particular attention to larger port sites that may require fascial closure.
    • Skin closure is typically performed with absorbable sutures or skin adhesive.

14. Postoperative Management:

    • Monitor the patient in the recovery area for any immediate complications.
    • Manage pain and provide care instructions, including activity restrictions and wound care.

15. Follow-Up:

    • Schedule a postoperative follow-up to monitor recovery and address any concerns.

This procedure should be carried out by an experienced surgeon proficient in laparoscopic techniques. It's important to note that modifications to this protocol may be necessary based on the patient's anatomy, intraoperative findings, and specific clinical scenarios.